Registered Nurse Care Manager for Population Health

Job Summary

Reporting to the Manager of Population Health and/or their designee, the Maryland Primary Care Program (MDPCP) RN Care Manager is expected to coordinate overall care management for assigned patients in accordance with MDPCP protocols, while supporting other members of the care team. 

The RN Care Manager (CM) will be responsible for the provision of patient-centered nursing care in the primary care setting, helping patients and their families to support the patient’s self-management of chronic conditions. Duties will be performed in accordance with program guidelines. As a MDPCP RN CM, he or she will provide direct nursing and telephonic services to patients, collect and assess individual patient data, assist with the development and maintenance of care plans, update data bases and monitor their patients’ progress in setting and achieving goals that are a part of their care plans. The RN CM will also document and communicate the interventions they deploy, and their outcomes, in accordance with Total Health Cares (THC’s) and MDPCP standards and protocols. The RN CM will collaborate with other licensed and unlicensed care providers as appropriate. 

Contacts and interactions vary and may involve multiple constituencies such as direct interaction with THC’s executive management, community organizers, the general public, THC’s patients, physicians, colleagues, assigned staff, vendors, contractors and consultants for the purpose of providing and exchanging information.

Example of Essential Job Functions  

•  Collaborate with multi-disciplinary team to address both physical and psychological aspects of health to provide care for the whole patient
• Coordinate care management for chronic disease and population health
• Provide complex medication management
• Utilize assessment skills to evaluate patient needs and formulate a plan of care, as part of the multi-disciplinary care team
• Revise outcomes and interventions based on results of ongoing evaluation, collaborating with both the patient and members of the care team
• Identify patients at risk for poor outcomes and those who may require more intensive services such as referral to CHW and/or sub-specialists; provide additional outreach and frequent follow up (by phone and in-person) to this population in collaboration with CHW and sub-specialists
• Coordinate with community health worker (CHW) to support home visits with patients as needed to address chronic illnesses, and provide education about management and treatment of disease as needed
• Attend bi-weekly and monthly meetings (may be phone conferences) and trainings, as well as, other activities to facilitate optimal care processes
• Coordinate with the patient, family, and caregivers to resolve barriers to care
• Support patient education on health promotion, and management of disease
• Partner with patients in the development of self-management goals, evaluate ongoing status of goals along with other members of the interdisciplinary care team, and coordinate follow-up as needed
• Evaluate member/family strengths, health behaviors, and resources
• Provide medication reconciliation and adherence counseling, while assessing patient knowledge and barriers to adherence and self-care
• Participate in occasional research activities such as gathering data, developing brief reports, and implementation of protocols
• Spear-head an innovative program in a clinical setting

Minimum Education, Training and Experience Required

• Required: Graduate from an Accredited School of Nursing; Current Maryland Nursing License;
• Preferred: 3 years of related experience in chronic disease (diabetes, hypertension, heart disease) case management in an ambulatory or acute care setting; 
• Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams. 
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment
• Significant related experience with populations served may substitute for above requirement.

Required Knowledge, Skills and Abilities
 Knowledge of FQHC operations, operating principles, guidelines and bylaws. Excellent leadership, customer service, organizational and presentation skills as well as the ability to effectively communicate THC’s vision, and motivate others to achieve it organizationally, departmentally, and personally/professionally. Ability to communicate effectively (verbally and in writing). Ability to plan and organize work initiatives to successfully accomplish center/organizational goals and objectives. Ability to multi-task, prioritize and delegate as appropriate. Strong analytical, problem solving and interpersonal skills. Ability to identify, develop and implement short/long-term strategic goals and objectives. Ability to develop and maintain customer relationships; influence, build credibility and trust. Ability to think critically as well as apply critical thinking skills. Ability to: ensure and advocate for quality healthcare and services; and, lead and manage a diverse staff. 

Licenses and Certifications

Current Maryland RN licensure and graduate of an accredited nursing program, BSN preferred.  

Current BLS certification. 

Valid Maryland driver’s license and access to an insured automobile that lists employee on the insurance policy.

Physical Demands 

Must have the use of sensory skills in order to effectively communicate and interact with other employees and the public through the use of the telephone and personal contact as normally defined by the ability to see, read, talk, hear, handle or feel objects and controls.

Ability to effectively use and operate various items of office related equipment, such as, but not limited to: personal computer, calculator, copier, and fax machine.

Ability to lift, carry, push or pull heavy objects in excess of 25lbs as well as squat, walk, climb, bend, crouch, stoop, kneel, stand, grasp, reach, pull and repetitive motions.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.